Progress in radiology: historical review of the changing concepts of lower esophageal anatomy: 430 B.C.--1977

The Angle of His as a Measurable Element of the Anti-reflux Mechanism

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common condition, resulting from the loss of the anti-reflux barrier. Laparoscopic fundoplication is the surgical procedure of choice for treatment of GERD; however, there remains a debate on the exact mechanism through which it prevents reflux.

OBJECTIVES

Our aim was to understand the relationship between reflux, fundoplication, and the angle of His on an experimental model.

METHODS

The study was conducted on four groups of fresh explanted swine stomachs: control group, myotomy, myotomy with Nissen fundoplication, and myotomy with Toupet fundoplication. The stomachs were placed in a specially designated container on an inclinable platform which would increase the hydrostatic pressure on the esophago-gastric junction. Measurements of the angle of His using fluoroscopy and the esophago-gastric orifice area using endoscopy were performed, and the occurrence of reflux was documented.

RESULTS

Each group of the study contained nine swine stomachs. In the control and myotomy groups, the angle became wider as the incline level increased the pressure and was significantly different between the groups (p < .001). Both groups demonstrated an increase in the orifice area as the incline level increased the pressure. There was a significant correlation between the angle of His and the area of the esophago-gastric orifice (p < .001). In the control group, the reflux began at the 0°. In the myotomy group, it began at the + 15° incline (less pressure). Reflux rarely occurred in the Nissen and Toupet groups, with the breaking point being mostly defined as "beyond - 30°". A significant difference was noted in the occurrence of reflux between fundoplication and the non-fundoplication groups (p < 0.001), while there was no significant difference between the Toupet and Nissen groups (p = 0.134). Analysis showed a significant independent correlation between both the angle of His and the orifice area with the presence of reflux (p = .002 and p = .024 respectively).

CONCLUSIONS

In this study, we developed an experimental model to enable careful evaluation of the elements of the anti-reflux mechanism, of which, the angle of His has a measurable element. We demonstrated that as the angle of His becomes wider the esophago-gastric orifice area becomes larger. Additionally, a wider angle of His and a larger esophago-gastric orifice area were correlated independently with more reflux. This suggests that the fundoplication creates an acute angle of His which is correlated with a smaller area of the esophago-gastric orifice and eventually with a lower incidence of reflux.

Pelvic radiography as a non-invasive screening tool for hiatal hernia in children with cerebral palsy

The diagnosis of hiatal hernia (HH), causing severe gastroesophageal reflux disease and complications in children with cerebral palsy (CP) is cumbersome because invasive investigations are required for diagnosis. Hip displacement, one of the most common complications in children with CP, can be diagnosed with a simple pelvic radiograph. This study aimed to evaluate the association between the severity of hip displacement and HH and the diagnostic accuracy of Reimers' hip migration percentage (MP) on pelvic radiography in assessing the presence of HH. A total of 52 children with CP (27 boys, 25 girls; mean age, 6.3 years; range, 0.6-17.4 years) who underwent esophagogastroduodenoscopy, upper gastrointestinal series and pelvic radiography between March 2013 and February 2020 were recruited. Demographic and clinical characteristics, as well as endoscopic and radiological findings, were evaluated and statistically analyzed. HH was defined as ≥ 2 cm proximal displacement of the gastroesophageal junction identified in esophagogastroduodenoscopy or upper gastrointestinal series, and MP was calculated by evaluating the pelvic radiograph. Of the 52 children enrolled in this study, HH was diagnosed in 18 children (34.6%). When the patients were classified and analyzed according to the MP result, HH was observed in 10%, 26.7%, and 70.6% in MP <33%, MP 33%-39%, and MP > 40% groups, respectively (P < .001). The optimal MP cutoff of 36.5% distinguished pediatric CP patients with HH from those without HH with a sensitivity of 78%, specificity of 68%, a positive predictive value of 56.0%, and a negative predictive value of 85.2%, respectively. The application of MP and the severity of hip displacement, which can be easily measured by simple radiography, may be useful and reliable in screening for detecting HH in children with CP. Retrospectively registered. This study was approved by the Institutional Review Board of Seoul National University Bundang Hospital (IRB No. B-2007-627-106).

Factors associated with hiatal hernia in neurologically impaired children

BACKGROUND

Hiatal hernia is clinically important because it impairs the protective mechanism that prevents gastroesophageal reflux-induced injury. Diagnosing hiatal hernia is more important in neurologically impaired children because hiatal hernia-induced gastroesophageal reflux often causes severe complications such as aspiration pneumonia or malnutrition. We aimed to evaluate the patient characteristics and early predictors of hiatal hernia in neurologically impaired children.

METHODS

We retrospectively investigated 97 neurologically impaired children who underwent esophagogastroduodenoscopy and upper gastrointestinal series between March 2004 and June 2019. Demographic and clinical characteristics, as well as endoscopic and radiological findings, were statistically analyzed.

RESULTS

Of the 97 children recruited, 22 (22.7%) had hiatal hernia. When comparing the non-hiatal hernia group with the hiatal hernia group, neurological disease longer than 6 months (odds ratio 10.9, 95% confidence interval 1.2-96.5), wasting (odds ratio 4.6, 95% confidence interval 1.3-16.3), enteral tube feeding (odds ratio 9.2, 95% confidence interval 1.6-53.0), and history of aspiration pneumonia (odds ratio 6.5, 95% confidence interval 1.2-34.5) were identified as early predictors of hiatal hernia.

CONCLUSIONS

Timely identification of predictors of developing hiatal hernia in neurologically impaired children is important for early diagnostic confirmation to initiate optimal medical or surgical treatment of hiatal hernia to avoid serious complications such as aspiration pneumonia and malnutrition.

ANATOMIC DAMAGE OF THE LOWER ESOPHAGEAL SPHINCTER AFTER SUBTOTAL GASTRECTOMY

AIM

Dysfunction of the lower esophageal sphincter (LES), gastroesophageal reflux disease, and erosive esophagitis in patients undergoing subtotal gastrectomy are commonly recognized occurrences, but until now the causes remain unclear. The hypothesis of this study is that subtotal gastrectomy provokes changes on the LES resting pressure and its competence, due to the anatomical damage of it, given that the oblique "Sling" fibers, one of the muscular components of the LES, are transected during this surgical procedure.

METHODS

Seven adult mongrel dogs (18-30 kg) were anesthetized and admitted for transection of the proximal stomach. Later, the proximal gastric remnant was closed by a suture. Intraoperatively, slow pull-through LES manometries were performed on each dog, under basal conditions (with the intact stomach), and in the closed proximal gastric remnant. The mean of these measurements is presented, with each dog serving as its control.

RESULTS

The mean LES pressure (LESP) measured in the proximal gastric remnant, compared with the LESP in the intact stomach, was decreased in five dogs, increased in one dog, and remained unchanged in other dogs.

CONCLUSION

The upper transverse transection of the stomach and closing the stomach remnant by suture provoke changes in the LESP. We suggested that these changes in the LESP are secondary to transecting the oblique "Sling" fibers of the LES, one of its muscular components. The suture and closing of the proximal gastric remnant reanchor these fibers with more, less, or the same tension, whether or not modifying the LESP.

Laparoscopic gastric fundus tamponade: a novel adaptation of the Toupet fundoplication for large paraesophageal hernia repair

BACKGROUND

Laparoscopic repair of large paraesophageal hiatal hernia with defects too large to close primarily or greater than 8 cm is technically challenging. The ideal repair remains unclear and is often debated. Utilizing the gastric fundus as an autologous patch to obliterate and tamponade large hiatal defects may offer a new solution. The aim of this study was to evaluate the short-term outcomes following partial posterior fundoplication with gastric fundus tamponade.

METHODS

Retrospective chart review and prospective patient follow up was conducted on patients who underwent laparoscopic hiatal hernia repair between 2015 and 2019 by a single surgeon. Basic demographics, pre-operative diagnoses, operative technique, and clinical outcomes were recorded.

RESULTS

Fifteen patients underwent the described technique for repair of large paraesophageal hiatal hernia. All procedures were completed laparoscopically with a short post-operative length of stay (mean of 3 days) and no 30-day readmissions. The majority of patients reported resolution of their pre-operative symptoms. Only one patient required surgery for emergent indications and the same patient was the only mortality in the study, which was secondary to respiratory failure, necrotizing pneumonia, and sepsis as a result of gastric volvulus and obstruction.

CONCLUSION

Utilizing the gastric fundus as an autologous patch to repair large hiatal hernia may be a safe and efficacious solution with good short-term outcomes. However, further studies should be conducted to elucidate long-term results.

Gastrointestinal Dysmotility in the Elderly

The number of persons 60 years and older has increased 3-fold between 1950 and 2000. Aging alone does not greatly impact the gastrointestinal (GI) tract. Digestive dysfunction, including esophageal reflux, achalasia, dysphagia, dyspepsia, delayed gastric emptying, constipation, fecal incontinence, and fecal impaction, is a result of the highly prevalent comorbid conditions and the medications with which those conditions are treated. A multidisciplinary approach with the expertise of a geriatrician, gastroenterologist, neurologist, speech pathologist, and physical therapist ensures a comprehensive functional and neurological assessment of the older patient. Radiographic and endoscopic evaluation may be warranted in the evaluation of the symptomatic older patient with consideration given to the risks and benefits of the test being used. Treatment of the digestive dysfunction is aimed at improving health-related quality of life if cure cannot be achieved. Promotion of healthy aging, treatment of comorbid conditions, and avoidance of polypharmacy may prevent some of these digestive disorders. The age-related changes in GI motility, clinical presentation of GI dysmotility, and therapeutic principles in the symptomatic older patient are reviewed here.

Measuring movement and location of the gastroesophageal junction: research and clinical implications

Understanding the physiology of gastroesophageal junction (GEJ) is important as failure of its function is associated with reflux disease, hiatus hernia, and cancer. In recent years, there have been impressive developments in high resolution technologies allowing measurement of luminal pressure, pH, and impedance. One obvious deficiency is the lack of technique to monitor the movement and location of the GEJ over a prolonged period of time. Proximal movement of the GEJ during peristalsis and transient lower esophageal sphincter relaxations (TLESRs) is due to shortening of the longitudinal muscle of the esophagus. Techniques for measuring shortening include fluoroscopic imaging of mucosal clip, high-frequency intraluminal ultrasound, and high resolution manometry, but these techniques have limitations. Short segment reflux is recently found to be more common than traditional reflux and may account for the high prevalence of intestinal metaplasia and cancer seen at GEJ. While high resolution pHmetry is available, there is no technique that can reliably and continuously measure the position of the squamocolumnar junction. A new technique is recently reported allowing a precise and continuous measurement of the GEJ based on the principle of Hall effect. Reported studies have validated its accuracy both on the bench and against the gold standard, fluoroscopy. It has been used alongside high resolution manometry in studying the behavior of the GEJ during TLESRs and swallows. While there are challenges associated with this new technique, there are promising ongoing developments. There is exciting time ahead in research and clinical applications for this new technique.

Clinical significance of hiatal hernia

The relationship between hiatal hernias and gastroesophageal reflux disease (GERD) has been greatly debated over the past decades, with the importance of hiatal hernias first being overemphasized and then later being nearly neglected. It is now understood that both the anatomical (hiatal hernia) and the physiological (lower esophageal sphincter) features of the gastroesophageal junction play important, but independent, roles in the pathogenesis of GERD, constituting the widely accepted "two-sphincter hypothesis." The gastroesophageal junction is an anatomically complex area with an inherent antireflux barrier function. However, the gastroesophageal junction becomes incompetent and esophageal acid clearance is compromised in patients with hiatal hernia, which facilitates the development of GERD. Of the different types of hiatal hernias (types I, II, III, and IV), type I (sliding) hiatal hernias are closely associated with GERD. Because GERD may lead to reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma, a better understanding of this association is warranted. Hiatal hernias can be diagnosed radiographically, endoscopically or manometrically, with each modality having its own limitations, especially in the diagnosis of hiatal hernias less than 2 cm in length. In the future, high resolution manometry should be a promising method for accurately assessing the association between hiatal hernias and GERD. The treatment of a hiatal hernia is similar to the management of GERD and should be reserved for those with symptoms attributable to this condition. Surgery should be considered for those patients with refractory symptoms and for those who develop complications, such as recurrent bleeding, ulcerations or strictures.

Clinical significance of hiatal hernia

The relationship between hiatal hernias and gastroesophageal reflux disease (GERD) has been greatly debated over the past decades, with the importance of hiatal hernias first being overemphasized and then later being nearly neglected. It is now understood that both the anatomical (hiatal hernia) and the physiological (lower esophageal sphincter) features of the gastroesophageal junction play important, but independent, roles in the pathogenesis of GERD, constituting the widely accepted "two-sphincter hypothesis." The gastroesophageal junction is an anatomically complex area with an inherent antireflux barrier function. However, the gastroesophageal junction becomes incompetent and esophageal acid clearance is compromised in patients with hiatal hernia, which facilitates the development of GERD. Of the different types of hiatal hernias (types I, II, III, and IV), type I (sliding) hiatal hernias are closely associated with GERD. Because GERD may lead to reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma, a better understanding of this association is warranted. Hiatal hernias can be diagnosed radiographically, endoscopically or manometrically, with each modality having its own limitations, especially in the diagnosis of hiatal hernias less than 2 cm in length. In the future, high resolution manometry should be a promising method for accurately assessing the association between hiatal hernias and GERD. The treatment of a hiatal hernia is similar to the management of GERD and should be reserved for those with symptoms attributable to this condition. Surgery should be considered for those patients with refractory symptoms and for those who develop complications, such as recurrent bleeding, ulcerations or strictures.

Endoscopically defined gastroesophageal junction coincides with the anatomical gastroesophageal junction

INTRODUCTION

The gastroesophageal junction is a complex anatomic area. Precise endoscopic assessment of the gastroesophageal junction is of utter importance, especially regarding Barrett's esophagus and neoplasms of the gastroesophageal junction. There has been a lack of a validated definition of the endoscopic gastroesophageal junction.

METHODS

Seven patients scheduled for resection of the gastroesophageal junction were included. Before surgery, gastroscopy was performed and the gastroesophageal junction was assessed. If there was disparity between the endoscopic gastroesophageal junction and the Z-line, the gastroesophageal junction was marked with India ink tattooing. Postoperatively the resection specimens were evaluated and the anatomical gastroesophageal junction was compared with the endoscopic.

RESULTS

In all seven patients the measured difference between the gastroesophageal junction and the endoscopic junction was <5 mm.

CONCLUSIONS

The upper margin of the longitudinal folds of the stomach can be used as an appropriate endoscopic definition of the gastroesophageal junction.

Recent advances in the surgical treatment of achalasia and gastroesophageal reflux disease

Achalasia and gastroesophageal reflux disease (GERD) represent diverse physiologic disorders both of which result from lower esophageal sphincter (LES) dysfunction. Fortunately, both diseases are benign and amenable to surgically corrective therapies. Achalasia is characterized by destruction of the smooth muscle ganglion cells of the myenteric plexus (Auerbach) resulting in motor dysfunction, incomplete LES relaxation, and progressive esophageal dilation. GERD is frequently characterized by hypotonia or shortening of the LES. Local anatomical derangements such as a hiatal hernia (eg, sliding type I hernia) can predispose to GERD. Other predisposing factors for GERD include obesity, smoking, alcohol, and pregnancy. Transient LES relaxation is the most significant factor in the development of GERD. Transient LES relaxations last from 10 to 45 seconds and are not related to swallowing. The diagnostic workup of achalasia and GERD may include barium esophagram, upper gastrointestinal endoscopy, pH monitoring, and esophageal manometry. The different medical treatment options for achalasia comprise pharmacologic treatment, botulinum toxin, and balloon dilation. Surgical interventions include Heller myotomy, which is usually combined with a partial fundoplication. GERD is managed by treating the predisposing factors, using medications (ie, anatacids or proton pump inhibitors) and surgery (ie, fundoplication). Recently, endoluminal therapy has been employed in the treatment of GERD with promising short-term results.

Approaches to the diagnosis and grading of hiatal hernia

Hiatus hernia refers to conditions in which elements of the abdominal cavity, most commonly the stomach, herniate through the oesophageal hiatus into the mediastinum. With the most common type (type I or sliding hiatus hernia) this is associated with laxity of the phrenooesophageal membrane and the gastric cardia herniates. Sliding hiatus hernia is readily diagnosed by barium swallow radiography, endoscopy, or manometry when greater than 2 cm in axial span. However, the mobility of the oesophagogastric junction precludes the reliable detection of more subtle disruption by endoscopy or radiography. Detecting lesser degrees of axial separation between the lower oesophageal sphincter and crural diaphragm can only be reliably accomplished with high-resolution manometry, a technique that permits real time localization of these oesophagogastric junction components without swallow or distention related artefact.

Pharmacological dissection of the human gastro-oesophageal segment into three sphincteric components

Quantifications of gastro-oesophageal anatomy in cadavers have led some to identify the lower oesophageal sphincter (LOS) with the anatomical gastric sling-clasp fibres at the oesophago-cardiac junction (OCJ). However, in vivo studies have led others to argue for two overlapping components proximally displaced from the OCJ: an extrinsic crural sphincter of skeletal muscle and an intrinsic physiological sphincter of circular smooth-muscle fibres within the abdominal oesophagus. Our aims were to separate and quantify in vivo the skeletal and smooth muscle sphincteric components pharmacologically and clarify the description of the LOS. In two protocols an endoluminal ultrasound-manometry assembly was drawn through the human gastro-oesophageal segment to correlate sphincteric pressure with the anatomic crus. In protocol I, fifteen normal subjects maintained the costal diaphragm at inferior/superior positions by full inspiration/expiration (FI/FE) during pull-throughs. These were repeated after administering atropine to suppress the cholinergic smooth-muscle sphincter. The cholinergic component was reconstructed by subtracting the atropine-resistant pressures from the full pressures, referenced to the anatomic crus. To evaluate the extent to which the cholinergic contribution approximated the full smooth-muscle sphincter, in protocol II seven patients undergoing general anaesthesia for non-oesophageal pathology were administered cisatracurium to paralyse the crus. The smooth-muscle sphincter pressures were measured after lung inflation to approximate FI. The cholinergic smooth-muscle pressure profile in protocol I (FI) matched closely the post-cisatracurium smooth-muscle pressure profile in protocol II, and the atropine-resistant pressure profiles correlated spatially with the crural sling during diaphragmatic displacement. Thus, the atropine-resistant and cholinergic pressure contributions in protocol I approximated the skeletal and smooth muscle sphincteric components. The smooth-muscle pressures had well-defined upper and lower peaks. The upper peak overlapped and displaced rigidly with the crural sling, while the distal peak separated from the crus/upper-peak by 1.1 cm between FI and FE. These results suggest the existence of separate upper and lower intrinsic smooth-muscle components. The 'upper LOS' overlaps and displaces with the crural sling consistent with a physiological LOS. The distal smooth-muscle pressure peak defines a 'lower LOS' that likely reflects the gastric sling/clasp muscle fibres at the OCJ. The distinct physiology of these three components may underlie aspects of normal sphincteric function, and complexity of sphincter dysfunction.

The role of the hiatus hernia in gastro-oesophageal reflux disease

A sliding hiatus hernia disrupts both the anatomy and physiology of the normal antireflux mechanism. It reduces lower oesophageal sphincter length and pressure, and impairs the augmenting effects of the diaphragmatic crus. It is associated with decreased oesophageal peristalsis, increases the cross-sectional area of the oesophago-gastric junction, and acts as a reservoir allowing reflux from the hernia sac into the oesophagus during swallowing. The overall effect is that of increased oesophageal acid exposure. The presence of a hiatus hernia is associated with symptoms of gastro-oesophageal reflux, increased prevalence and severity of reflux oesophagitis, as well as Barrett's oesophagus and oesophageal adenocarcinoma. The efficacy of treatment with proton pump inhibitors is reduced. Our view on the significance of the sliding hiatus hernia in gastro-oesophageal reflux disease has changed enormously in recent decades. It was initially thought that a hiatus hernia had to be present for reflux oesophagitis to occur. Subsequently, the hiatus hernia was considered an incidental finding of little consequence. We now appreciate that the hiatus hernia has major patho-physiological effects favouring gastro-oesophageal reflux and hence contributing to oesophageal mucosal injury, particularly in patients with severe gastro-oesophageal reflux disease.

Responses of human clasp and sling fibers to neuromimetics

BACKGROUND AND AIMS

It has previously been demonstrated that clasp and sling fibers at the human gastroesophageal junction respond differently to acetylcholine (Ach). The present study was undertaken to investigate the differences between the physiological and pharmacological properties of the two types of muscle fiber.

METHODS

Recordings were made of the isometric tension of human sling and clasp fibers in response to Ach, dopamine (DA), phenylephrine (Phe), and isoprenaline (Iso). These specimens were obtained from 18 patients who were operated on for esophageal cancer.

RESULTS

Both Ach and Phe increased the tension of the two types of muscle; the values in the Ach group being 3-4-fold greater than those in the Phe group, while Iso decreased the tension of both types of muscle strip. The tension of the sling fibers was reduced by DA at lower concentration, and then increased gradually as the concentration was increased. In contrast, the tension of the clasp fibers did not obviously change when the concentration of DA was lower, but a slow elevation of tension was seen with the increase in DA concentration.

CONCLUSIONS

The sensitivities and maximum responses to each agent differed between the clasp fibers and sling fibers. This suggests that the two kinds of fiber have different roles in establishing tension in the lower esophageal sphincter, with implications for the medical and surgical treatment of disorders in this region.

Supraesophageal complications of reflux disease and hiatal hernia

A unifying theme of gastroesophageal reflux disease (GERD) is increased acid exposure on vulnerable epithelia. In most cases, the vulnerable epithelium is the esophagus, but alternatively it may be that of the supraesophageal terrain, which includes the larynx, pharynx, and airways. In 50% to 94% of patients with GERD, hiatal hernia is a significant pathophysiologic factor. The esophagogastric junction (EGJ) is anatomically and physiologically complex, making it vulnerable to dysfunction by several mechanisms, including transient relaxations of the lower esophageal sphincter (LES), hypotensive LES, and anatomic disruption. The importance of hiatal hernia is obscured by imprecise use of the term and by the misconception that it is an all-or-none, one-dimensional phenomenon. Rather, hiatal hernia can be viewed as a continuum of progressive disruption of the EGJ, with larger hernias being of greater significance and invoking several pathogenetic mechanisms. The dynamic anatomy of the EGJ highlights the difficulty of defining hiatal hernia and of elucidating the relation between hiatal hernia, the diaphragmatic hiatus, the LES, and GERD, including supraesophageal reflux.

Cardiomyotomy in achalasia: which fibers do we cut?

Until now, it has not been quite clear which muscular fibers are cut when a cardiomyotomy for achalasia is carried out. In the present report, in a human achalasic gastroesophageal specimen, the mucosa of the stenotic segment was stripped off, allowing the fibers of the inner muscular coat to be seen. In addition, three cardiomyotomies at different sites were simulated. In achalasic specimens, the stenotic area is formed by the semicircular ('clasp') and oblique ('sling') muscular fibers. Different myotomies section these two muscular bands in distinct proportions. The stenotic segment in achalasia coincides topographically with the anatomic lower esophageal sphincter area. The site of cardiomyotomy is not irrelevant because this sphincter is not an annular muscle and the two muscular components of the sphincter can be sectioned in different ways. This may be important in post-operative results with regard to the relief of dysphagia and the appearance of gastroesophageal reflux.

Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia

BACKGROUND & AIMS

This study aimed to determine if hiatal hernia influences vulnerability to reflux and transient lower esophageal sphincter relaxation (tLESR) during gastric distention in patients with gastroesophageal reflux disease (GERD).

METHODS

Eight normal subjects and 15 patients with GERD were studied. A metal clip attached to the squamocolumnar junction (SCJ) was beneath the hiatus in all control subjects. Eight GERD patients with >/=1-cm SCJ-hiatus separation were considered hernia patients, and 7 with <1-cm separation were considered nonhernia patients. Manometry and esophageal pH were recorded for 30 minutes, after which the stomach was loaded with acid dextrose and the recording continued for 2 hours with intragastric air infusion of 15 mL/min.

RESULTS

Baseline reflux was comparable among groups. Gastric distention increased the frequency of reflux by the tLESR mechanism in all groups. Controls and nonhernia patients had median increases of 4.0 and 4.5 in tLESR frequency, respectively, and hernia patients had a median increase of 9.5/h. tLESR frequency was highly correlated with the SCJ-hiatus separation (r = 0.76; P < 0.001).

CONCLUSIONS

Gastric air infusion was a potent stimulus for tLESR and reflux. The resultant tLESR frequency was directly proportional to the separation between the SCJ and hiatus, suggesting that the perturbed anatomy associated with hiatal hernia predisposed to eliciting tLESRs in patients with GERD.

Pressure-overload-induced sliding hiatal hernia in power athletes

Sliding hiatal hernias are a common condition thought to occur with increasing age secondary to a degenerative process. The incidence of sliding hiatal hernias in the general population is 0.5%. Although the prevalence in the Western world is thought to be significantly higher, with approximately 60% of geriatric patients in North America having a hiatal hernia on radiologic studies. Thus, the primary etiology of the sliding hiatal hernia is thought to be degeneration of the phrenoesophageal ligament. Most hiatal hernias occurring in young adults are idiopathic. There has been speculation of a stress-induced hiatal hernia from repeated episodes of elevated intra-abdominal pressure, and to date there is one report of a pressure-overload-induced hiatal hernia occurring in an elite body builder. The prevalence of hiatal hernia in young male power athletes has yet to be examined. Therefore, we examined eight male elite power athletes and seven male non-weightlifters, matched for age, via fluoroscopy with barium swallow to test the hypothesis that pressure overload can induce hiatal hernias in young adults.

Impact of fundoplication on bolus transit across esophagogastric junction

This study analyzed the effect of fundoplication on the mechanics of liquid and solid bolus transit across the esophagogastric junction (EGJ). The squamocolumnar junction was endoscopically clipped in seven controls, seven hiatal hernia patients, and seven patients after laparoscopic Nissen fundoplication. Concurrent manometry and fluoroscopy were done during swallows of liquid barium and a 13-mm-diameter marshmallow. The EGJ opening, pressure gradients, transit efficacy, and axial motion were measured. The axial motion of the EGJ was reduced in the fundoplication and hiatal hernia patients. The opening dimensions at the squamocolumnar junction were similar among groups, but in each case the constriction limiting flow to the stomach was at the hiatus and this was substantially narrowed with fundoplication. As a result, liquid intrabolus pressure was increased and marshmallow transit frequently required multiple swallows. We conclude that fundoplication limits the axial mobility of the EGJ and leads to a restricted hiatal opening. These alterations decrease the efficacy of solid and liquid transit into the stomach and are potential causes of dysphagia in this population.

Aortic valve thickening associated with power training: is it pressure overload?

This is a first report of aortic valve thickening secondary to intermittent hypertensive episodes experienced with weight lifting.

Anatomy and physiology of the gastroesophageal junction

The gastroesophageal junction is a complex valve composed of a smooth muscle element (LES) and a diaphragmatic element. These normally supplement each other to maintain competence in a static condition and during dynamic stresses associated with increased intra-abdominal pressure or swallowing. These sphincteric components also interact with each other pathophysiologically. During swallowing, large hernias impair the process of esophageal emptying, thereby prolonging acid clearance. The susceptibility to stress reflux inherent during periods of diminished LES pressure is also dramatically increased by disabling the diaphragmatic sphincter. These functional impairments of the gastroesophageal junction associated with hiatus hernia lead to increased esophageal acid exposure and offer one explanation for the chronicity of reflux disease.

Can pressure overload cause sliding hiatal hernia? A case report and review of the literature

We describe a hiatal hernia of moderate size in a 31-year-old competitive bodybuilder to raise the question of whether such hernias are more likely in young elite resistance-trained athletes as a consequence of attempts to increase intra-abdominal pressure and thus decrease the strain on the lumbar spine.

Attenuation of esophageal shortening during peristalsis with hiatus hernia

BACKGROUND & AIMS

Minimal quantitative information exists on esophageal shortening during peristalsis in the human esophagus. The aim of this study was to ascertain the effect of hiatus hernia on longitudinal muscle-mediated peristaltic esophageal shortening.

METHODS

Seven volunteers and 11 patients with hiatal hernia had metal clips endoscopically affixed at the squamocolumnar junction and 3-5 cm proximal to it (n = 11). Location of the lower esophageal sphincter and axial clip movement were assessed using concurrent manometry and videofluoroscopy during barium swallows in a supine and upright posture with and without abdominal compression.

RESULTS

Three subject groups were defined by the proximity of the squamocolumnar junction to the diaphragmatic hiatus: group 1, < or = 0 cm; group 2, between 0 and 2 cm; and group 3, > or = 2 cm. Peristaltic esophageal shortening was progressively diminished, re-elongation progressively prolonged, and the degree of contraction observed in the distal esophageal segment reduced with progressive degree of hiatus hernia. There was minimal mobility of the squamocolumnar junction relative to the hiatus with posture or abdominal compression.

CONCLUSIONS

Longitudinal muscle contraction during peristalsis normally causes transient elevation of the squamocolumnar junction above the diaphragm. Esophageal shortening during primary peristalsis is reduced with increasing degree of hiatus hernia, suggesting that there is diminished opposition of longitudinal muscle contraction from the phrenoesophageal attachments.

Single dilation of symptomatic Schatzki rings. A prospective evaluation of its effectiveness

This study investigates the effect of a single dilation on the morphology of the lower esophageal ring and on the clinical course of symptomatic patients. Thirty-three patients were studied prospectively for a mean period of 24.3 +/- 19.2 months. Passage of a large bougie (46-58 F) resulted in a rupture of the ring in each instance and its mean diameter increased from 11.4 +/- 3.6 to 17.2 +/- 4.1 mm. No complications occurred, and all patients were symptom-free at the first follow-up examination four weeks after dilation. However, late symptomatic recurrences were frequent. After one year, the estimated proportion of patients remaining free of symptoms was 68% after two years 35%, and after five years 11%. Repeated treatments were performed with similar ease and effectiveness; again, no complications were encountered. Neither the initial ring size nor the presence or absence of esophagitis determined the likelihood of symptomatic recurrences. It is concluded that single dilations of symptomatic lower esophageal rings are safe, easily performed, and well tolerated. Long-term cure of episodic dysphagia is rare, but recurrences can be successfully treated by repeated dilations.

Communicating intrathoracic hydrocele

Tense ascites may cause herniation of parietal peritoneal reflection into the mediastinum at the gastroesophageal junction. This may produce a mass visible on chest radiograph and computed tomography (CT). This communicating intrathoracic hydrocele may occur in the absence of hiatal hernia and may be confused with other middle mediastinal fluid collections including necrotic tumor, abscess, cyst of foregut origin, or pancreatic pseudocyst. Recognition of this entity in patients with ascites should prevent diagnostic confusion and unnecessary further evaluation.

Mediastinal pseudotumor due to passage of ascites through the esophageal hiatus

Ascites can extend from the peritoneal cavity into the posterior mediastinum through the esophageal hiatus. This mediastinal fluid can simulate the appearance of a mediastinal tumor. Demonstration of hiatal hernia and continuity between the thoracic and abdominal fluid assist in establishing the correct diagnosis.

Predictive relationship of hiatal hernia to reflux esophagitis

The relationship between hiatal hernia and reflux esophagitis was compared in 93 patients who underwent both radiographic and endoscopic examination of the esophagus. In 46 patients with a normal esophagus shown endoscopically, hiatal hernia was present in 59%, while 94% of 47 patients with reflux esophagitis had hiatal hernia. The positive and negative predictive values for hiatal hernia in diagnosing or excluding esophagitis were 62% and 86%, respectively. Extrapolation of these data and review of the literature suggest that much of the confusion concerning the relationship between hiatal hernia and reflux esophagitis is based on reports of populations with considerable variation in the prevalence of esophagitis and in which the radiographic criteria for diagnosing hiatal hernia have not been uniformly applied.

Correlation between manometric and roentgenologic findings of diseases of the esophagus in infants and children

Roentgenologic and manometric findings in diseases of the esophagus in infants and children were compared. With both procedures combined it was possible to determine the exact localization of the lower esophageal sphincter. For the demonstration of gastroesophageal reflux the roentgenologic water siphon test was used. The excellent correspondence of the results of the water siphon test with manometric findings demonstrated the reliability of this roentgenologic method for detection of reflux. In borderline cases simultaneous manometric and roentgenologic studies were also of great use for demonstration of hiatus hernia.

Reflux esophagitis: radiologic-endoscopic correlation in 39 symptomatic cases

Thirty-nine consecutive patients with symptoms suggestive of reflux esophagitis underwent a double contrast upper gastrointestinal series and subsequently had endoscopy with biopsy. In a control group of 164 consecutive patients without symptoms of esophagitis a double contrast examination was done with the same method. We have found a significant increase of the diameter of the esophagus in its distal or cardiac segment (IDCE) in patients with esophagitis of Grades 1 and 2 when compared with the control group (p less than 0.001). Radiology was found to have correctly diagnosed 35 of the 39 cases (89.7%) and the majority of the patients had endoscopic signs of mild esophagitis.

Perimeter and location of the muscular gastroesophageal junction or 'cardia' in control subjects and in patients with reflux esophagitis or achalasia

The location and perimeter of the true muscular gastroesophageal junction or cardia were determined during operation in 6 patients with achalasia, in 20 control subjects, and in 40 patients with reflux esophagitis. These two latter groups were submitted to highly selective vagotomy, owing to duodenal ulcer in the control subjects and as part of the surgical technique in reflux esophagitis patients. The careful dissection and isolation of the distal 5-6 cm of the esophagus and esophagogastric junction permitted us to measure the location and perimeter very precisely. There was a very close correlation between the distance incisors-beginning of gastroesophageal sphincter measured preoperatively and the distance incisors-cardia measured during surgery. The cardia could be clearly identified by external inspection corresponding to the limit between the longitudinal muscle layer of the esophagus and the serosal surface of the stomach. The perimeter of the cardia in the patients with reflux esophagitis was significantly larger than the perimeter of the control subjects (p less than 0.001). Intraoperative manometry demonstrated that the external limit of the cardia corresponded to the beginning of the gastroesophageal sphincter. Patients with achalasia had significantly smaller perimeter than controls or reflux esophagitis patients (p less than 0.001).

Retrograde mucosal prolapse following a Heller's correction for achalasia of the esophageal cardia

Retrograde gastric mucosal prolapse into the esophageal vestibule producing incomplete obstruction, following a Heller's procedure for achalasia of the esophagus, is reported.